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Tang KWK, Millar BC, Moore JE. Improving health literacy of antibiotic use in people with cystic fibrosis (CF)-comparison of the readability of patient information leaflets (PILs) from the EU, USA and UK of 23 CF-related antibiotics used in the treatment of CF respiratory infections. JAC Antimicrob Resist 2023; 5:dlad129. [PMID: 38046567 PMCID: PMC10691746 DOI: 10.1093/jacamr/dlad129] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2023] [Accepted: 11/20/2023] [Indexed: 12/05/2023] Open
Abstract
Background Antibiotic adherence is poor amongst people with cystic fibrosis (CF). Low-quality patient information leaflets (PILs), which accompany prescription antibiotics, with poor readability may contribute to poor antibiotic adherence, with the potential for antimicrobial resistance (AMR) development. The aim of this study was to examine the readability of antibiotic PILs used to treat CF lung infections. Methods CF-related antibiotics (n = 23; seven classes: aminoglycosides, β-lactams, fluoroquinolones, macrolides/lincosamides, oxazolidinones, tetracyclines, trimethoprim/sulfamethoxazole) were investigated. Readability of PILs (n = 141; 23 antibiotics) from the EU (n = 40), USA (n = 42) and UK (n = 59) was calculated. Results Mean [± standard error of mean (SEM)] values for the Flesch Reading Ease (FRE) for EU, USA and UK were 50.0 ± 1.1, 56.2 ± 1.3 and 51.7 ± 1.1, respectively (FRE target ≥60). Mean (± SEM) values for the Flesch Kinkaid Grade Level (FKGL) for the EU, USA and UK were 9.0 ± 0.2, 7.5 ± 0.2 and 9.6 ± 0.2, respectively (FKGL target ≤8). US PILs were significantly shorter (P < 0.0001) in words (mean ± SEM = 1365 ± 52), than either UK or EU PILs, with fewer sentences (P < 0.0001), fewer words per sentence (P < 0.0001) and fewer syllables per word. The mean ( ± SEM) reading time of UK PILs (n = 59) was 12.7 ± 0.55 mins . Conclusions Readability of antibiotic PILs is poor. Improving PIL readability may lead to improved health literacy, which may translate to increased antibiotic adherence and AMR avoidance. Authors preparing written materials for the lay/patient CF community are encouraged to employ readability calculators, so that final materials are within recommended readability reference parameters, to support the health (antibiotic) literacy of their readers.
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Affiliation(s)
- Ka Wah Kelly Tang
- School of Biomedical Sciences, Ulster University, Cromore Road, Coleraine BT52 1SA Northern Ireland, UK
| | - Beverley C Millar
- School of Biomedical Sciences, Ulster University, Cromore Road, Coleraine BT52 1SA Northern Ireland, UK
- Laboratory for Disinfection and Pathogen Elimination Studies, Northern Ireland Public Health Laboratory, Belfast City Hospital, Lisburn Road, Belfast BT9 7AD Northern Ireland, UK
- Northern Ireland Regional Adult Cystic Fibrosis Centre, Level 8, Belfast City Hospital, Lisburn Road, Belfast BT9 7AB, Northern Ireland, UK
| | - John E Moore
- School of Biomedical Sciences, Ulster University, Cromore Road, Coleraine BT52 1SA Northern Ireland, UK
- Laboratory for Disinfection and Pathogen Elimination Studies, Northern Ireland Public Health Laboratory, Belfast City Hospital, Lisburn Road, Belfast BT9 7AD Northern Ireland, UK
- Northern Ireland Regional Adult Cystic Fibrosis Centre, Level 8, Belfast City Hospital, Lisburn Road, Belfast BT9 7AB, Northern Ireland, UK
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Stanford G, Morrison L, Brown C. Nebuliser systems for drug delivery in cystic fibrosis. Cochrane Database Syst Rev 2023; 11:CD007639. [PMID: 37942828 PMCID: PMC10633867 DOI: 10.1002/14651858.cd007639.pub3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2023]
Abstract
BACKGROUND Nebuliser systems are used to deliver medications to the lungs, to control the symptoms and the progression of lung disease in people with cystic fibrosis (CF). There are many different nebulised-medications prescribed for people with CF and there are many different types of nebuliser systems. Some of these nebulised medications are licenced for, and can be taken via only one type of nebuliser system; some are licensed for, and can be taken via more than one type of nebuliser system. This is an update to a previous systematic review. OBJECTIVES To assess the time efficiency, effectiveness, safety, cost and impact of use (e.g. burden of care, adherence, quality of life (QoL)) of different nebuliser systems, when used with different inhaled medications for people with CF. SEARCH METHODS We searched the Cochrane Cystic Fibrosis and Genetic Disorders Group Trials Register comprising references identified from comprehensive electronic database searches, handsearching of relevant journals and abstract books containing conference proceedings. We searched the reference lists of each study for additional publications and approached the manufacturers of both nebuliser systems and nebulised medications for published and unpublished data. We also searched online trial registries. Date of the most recent search: 9 August 2023. SELECTION CRITERIA Randomised controlled trials (RCTs) or quasi-RCTs comparing nebuliser systems, including conventional nebulisers, vibrating mesh technology (VMT) systems, adaptive aerosol delivery (AAD) systems and ultrasonic nebuliser systems. DATA COLLECTION AND ANALYSIS Two review authors independently assessed studies for inclusion. They also independently extracted data and assessed the risk of bias. A third review author assessed studies where agreement could not be reached. They assessed the certainty of the evidence using GRADE. MAIN RESULTS The search identified 216 studies with 33 of these (2270 participants) included in the review. These studies compared the delivery of tobramycin, colistin, dornase alfa, hypertonic saline and other solutions through the different nebuliser systems in children and adults with CF. This review demonstrates variability in the delivery of medication depending on the nebuliser system used. The certainty of the evidence ranged from low to very low. Some conventional nebuliser systems providing higher flows, higher respirable fractions, and smaller particles decrease treatment time, increase deposition (the amount of drug reaching the lung), and may be preferred by people with CF, as compared to other conventional nebuliser systems providing lower flows, lower respirable fractions and larger particles. Newer nebuliser systems using AAD, or VMT (or both) reduce treatment time compared to conventional systems. Deposition (as a percentage of priming dose) with AAD is greater than with conventional systems. VMT systems may give greater deposition than conventional systems when measuring sputum levels. The available data indicate that these newer systems are safe when used with an appropriate priming dose, which may be different to the priming dose used for conventional systems. There is an indication that adherence is maintained or improved and that individuals prefer AAD or VMT systems, but also that some nebuliser systems using VMT may be subject to increased system failures. There is limited, unclear evidence on the impact of different nebuliser systems on lung function and a lack of data on the impact of different nebuliser systems on our outcomes of quality of life (QoL), adverse effects, respiratory exacerbations and related implications, adherence, satisfaction, cost and device reliability. AUTHORS' CONCLUSIONS Newer technologies e.g. AAD and VMT have advantages over conventional systems in terms of treatment time, deposition as a percentage of priming dose, preference and adherence. Data are lacking for all varieties of medications which are used in CF care, including different inhaled antibiotics or hypertonic saline, with all delivery (nebuliser system) possibilities. Long-term RCTs are needed to evaluate different nebuliser systems to determine patient-focused outcomes (such as QoL and burden of care), safe and effective dosing levels of a wide variety of medications, clinical outcomes (such as hospitalisations and need for antibiotics), and an economic evaluation of their use. There are insufficient data to establish whether one nebuliser system is better than another overall. Clinicians should be aware of the variability in the performance of different nebuliser systems, compatibility with specific nebulised medication, and they must work with their patients to choose the best nebuliser system for each individual. This is likely to be an ongoing process as the needs and circumstances of each individual change over time.
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Affiliation(s)
- Gemma Stanford
- Department of Adult Cystic Fibrosis, Royal Brompton Hospital, Guys and St Thomas's NHS Foundation Trust, London, UK
| | - Lisa Morrison
- West of Scotland Adult CF Unit, Queen Elizabeth University Hospital (The Southern General Hospital), Glasgow, UK
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Eaton CK, Comer M, Pruette CS, Riekert KA. Medication adherence in youths with CKD: habits for success. Pediatr Nephrol 2023; 38:3791-3802. [PMID: 37306720 DOI: 10.1007/s00467-023-05976-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2022] [Revised: 04/03/2023] [Accepted: 04/04/2023] [Indexed: 06/13/2023]
Abstract
BACKGROUND Poor adherence habits are key contributors to nonadherence but there are few clinically feasible methods for evaluating adherence habits, particularly for youths with chronic kidney disease (CKD). This study investigated how participants' qualitative responses to three interview questions about adherence habits mapped to primary principles of habit formation and objectively measured medication adherence in youths with CKD. METHODS Participants (ages 11-21 years) were recruited from a pediatric nephrology clinic as part of a larger study. Participants' daily objective antihypertensive medication adherence was measured with an electronic pill bottle over a 4-week baseline period. Qualitative interviews about adherence habits and routines were conducted with a subset of participants (N = 18). RESULTS Clear qualitative differences emerged in how participants with high-medium adherence (80-100%) discussed adherence habits compared to participants with low adherence (0-79%). Participants with high-medium adherence discussed situational cues for taking medicine, including locations that cue adherence, step-by-step events leading up to taking medicine, and people who cue adherence. Participants with high-medium adherence regularly described taking medicine as "automatic," "second nature," and a "habit." Participants with low adherence rarely discussed these habit features nor did they explicitly acknowledge currently missing doses. Participants with low adherence tended to discuss challenges with organization and routines for taking medicine. CONCLUSIONS Evaluating patient responses to questions about adherence habits may uncover challenges with adherence habit formation, provide direction for habit-strengthening intervention focused on developing automatic cues for taking medication, and support adherence successes for youths with CKD. CLINICAL TRIAL REGISTRATION NUMBER NCT03651596. A higher resolution version of the Graphical abstract is available as Supplementary information.
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Affiliation(s)
- Cyd K Eaton
- Johns Hopkins University School of Medicine, 4200 Eastern Avenue, Baltimore, MD, 21224, USA.
| | - Margaret Comer
- Johns Hopkins University School of Medicine, 4200 Eastern Avenue, Baltimore, MD, 21224, USA
| | - Cozumel S Pruette
- Johns Hopkins University School of Medicine, 4200 Eastern Avenue, Baltimore, MD, 21224, USA
| | - Kristin A Riekert
- Johns Hopkins University School of Medicine, 4200 Eastern Avenue, Baltimore, MD, 21224, USA
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4
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Dawson S, Rodham K, Taylor J, Dewar J, Wildman M. "I think most people feel like healthcare professionals tell them to take their treatments and judge them for not taking them": reflexive thematic analysis of the views of adults with cystic fibrosis on how treatment adherence is discussed in healthcare. Psychol Health 2023:1-23. [PMID: 37667520 DOI: 10.1080/08870446.2023.2254318] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2023] [Revised: 08/23/2023] [Accepted: 08/27/2023] [Indexed: 09/06/2023]
Abstract
OBJECTIVE Previous research exploring patient-practitioner communication in relation to adherence in cystic fibrosis (CF) is limited. This UK study explored the views of adults with CF on how treatment adherence (related to all CF treatments) is discussed in routine CF care. METHODS 12 White British adults (ten females; aged 20-37 years; mean 30.1 years) with CF participated in semi-structured interviews. RESULTS Three overarching themes were developed through reflexive thematic analysis: (1) 'The power of language'; (2) 'Healthcare professionals do not recognise the importance of context'; and (3) '"Admitting" non-adherence is difficult'. The way in which adherence is discussed in adult CF care is viewed as paternalistic and infantilising. Participants reported that healthcare professionals do not always consider the desire to balance treatment-taking with living a normal life. Unwelcome responses from healthcare professionals, and the inability to accurately self-report the amount of treatment taken made it difficult to 'admit' non-adherence. CONCLUSIONS A culture change is needed in CF care such that people who struggle to take their treatments are not labelled as disobedient, wilfully disobeying orders from healthcare professionals in positions of authority. Instead, an open, honest, non-judgemental approach, as recommended by healthcare agencies for over a decade, should be adopted.
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Affiliation(s)
- Sophie Dawson
- Wolfson Adult Cystic Fibrosis Centre, Nottingham University Hospitals NHS Trust, Nottingham, UK
- Staffordshire Centre for Psychological Research, School of Health, Science and Wellbeing, Staffordshire University, Stoke-on-Trent, UK
| | - Karen Rodham
- Staffordshire Centre for Psychological Research, School of Health, Science and Wellbeing, Staffordshire University, Stoke-on-Trent, UK
- Institute of Psychology, Business and Human Sciences, University of Chichester, Chichester, UK
| | - Jennifer Taylor
- Staffordshire Centre for Psychological Research, School of Health, Science and Wellbeing, Staffordshire University, Stoke-on-Trent, UK
| | - Jane Dewar
- Wolfson Adult Cystic Fibrosis Centre, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Martin Wildman
- Sheffield Adult Cystic Fibrosis Centre, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
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5
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Wong CH, Smith S, Kansra S. Digital technology for early identification of exacerbations in people with cystic fibrosis. Cochrane Database Syst Rev 2023; 4:CD014606. [PMID: 37057835 PMCID: PMC10103544 DOI: 10.1002/14651858.cd014606.pub2] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/15/2023]
Abstract
BACKGROUND Cystic fibrosis (CF) is a life-limiting genetic condition affecting various organ systems including the gastrointestinal tract, endocrine system and especially the respiratory tract. Pulmonary exacerbations in CF result in increased symptoms, an acceleration in the rate of lung decline and an increased need for treatment. Early detection of infections or clinical worsening provides an opportunity for proactive treatment that may affect clinical outcomes. OBJECTIVES To evaluate whether digital technology can effectively predict pulmonary exacerbations to allow earlier intervention and improved health outcomes without increasing the burden of treatment in people with CF. SEARCH METHODS We used standard, extensive Cochrane search methods. We searched the Cochrane Cystic Fibrosis Trials Register and the reference lists of relevant articles and reviews on 13 October 2022. We searched Embase and the clinical trial registries on 3 January 2023. SELECTION CRITERIA We included randomised controlled trials (RCTs) or quasi-RCTs in people with CF looking at whether digital technology can effectively predict pulmonary exacerbations to allow earlier intervention and improved health outcomes without increasing the burden of treatment. DATA COLLECTION AND ANALYSIS: We used standard Cochrane methods. Our primary outcomes were 1. pulmonary exacerbations and 2. quality of life (QoL). Our secondary outcomes were 3. lung function, 4. hospitalisations, 5. intravenous (IV) antibiotics, 6. microbiology, 7. cost-effectiveness and 8. ADVERSE EVENTS We used GRADE to assess certainty of evidence. MAIN RESULTS We included three studies (415 participants) in people with CF aged 15 to 41 years over a 12-month period. One was a multicentre RCT, whilst two were single-centre RCTs. The three studies were mostly similar in their risk of bias, having low or unclear risk of selection bias but a high risk of detection bias, due to the unblinded design of these studies. The studies used a variety of digital technologies to monitor symptoms such as a digital symptom diary either with or without home spirometry monitoring. As the trials only included adults and older children, we are not certain that the results would apply to younger children. One of our primary outcomes was to assess time to detection of pulmonary exacerbation and number of pulmonary exacerbations identified between the intervention and routine care groups. We were largely unable to pool results in a meta-analysis due to the variety of methodologies and ways of reporting data. Two studies noted a shorter time to detection of exacerbations in the intervention group and one of these also reported that the intervention group had a shorter time to first exacerbation (hazard ratio for time to first exacerbation 1.45, 95% confidence interval (CI) 1.09 to 1.93), whilst a further study reported a shorter time to detection of exacerbations in the intervention group requiring oral or IV antibiotics compared to the control group (median: 70 (interquartile range (IQR) 123) days with intervention versus 141 (IQR 140) days with control; P = 0.02). However, all three studies were concordant in finding no probable effect on spirometry in the intervention groups when compared with their routine care groups over a 12-month period. We found that there is probably no difference between groups with regard to QoL scores across most domains except for Weight and Body Image, which favoured the usual care group. There is also probably no difference in the number of days of additional IV antibiotics needed or newly detected pathogens. No studies reported serious adverse events directly linked to the intervention and one study reported their smartphone application was generally well received. AUTHORS' CONCLUSIONS Pulmonary exacerbations are universally accepted to be detrimental to progression of CF-related lung disease, therefore, it is intuitive that early detection and intervention would help to improve outcomes. Digital technology provides an opportunity to detect physiological and symptomatic changes to identify exacerbations early. Our review found that digital technologies based on recording physiological change (spirometry) and symptoms probably allow earlier identification of exacerbations as a group. However, this may not reduce the number of exacerbations warranting IV antibiotics and there is probably no effect on lung function. This may be partly due to inconsistent definitions of pulmonary exacerbations and discrepancy in the management strategies for pulmonary exacerbations. Overall, the intervention may make little or no difference to QoL scores. The adherence to and uptake of digital technologies, especially those which include physiological measurements, are not well sustained and the costs of these need to be balanced against the clinical efficacy.
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Affiliation(s)
- Chu-Hai Wong
- Department of Paediatric Respiratory Medicine, Sheffield Children's Hospital NHS Trust, Sheffield, UK
| | - Sherie Smith
- Division of Child Health, Obstetrics & Gynaecology (COG), School of Medicine, University of Nottingham, Nottingham, UK
| | - Sonal Kansra
- Department of Paediatric Respiratory Medicine, Sheffield Children's Hospital NHS Trust, Sheffield, UK
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Gardner B, Arden MA, Brown D, Eves FF, Green J, Hamilton K, Hankonen N, Inauen J, Keller J, Kwasnicka D, Labudek S, Marien H, Masaryk R, McCleary N, Mullan BA, Neter E, Orbell S, Potthoff S, Lally P. Developing habit-based health behaviour change interventions: twenty-one questions to guide future research. Psychol Health 2023; 38:518-540. [PMID: 34779335 DOI: 10.1080/08870446.2021.2003362] [Citation(s) in RCA: 19] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
OBJECTIVE Habitual behaviours are triggered automatically, with little conscious forethought. Theory suggests that making healthy behaviours habitual, and breaking the habits that underpin many ingrained unhealthy behaviours, promotes long-term behaviour change. This has prompted interest in incorporating habit formation and disruption strategies into behaviour change interventions. Yet, notable research gaps limit understanding of how to harness habit to change real-world behaviours. METHODS Discussions among health psychology researchers and practitioners, at the 2019 European Health Psychology Society 'Synergy Expert Meeting', generated pertinent questions to guide further research into habit and health behaviour. RESULTS In line with the four topics discussed at the meeting, 21 questions were identified, concerning: how habit manifests in health behaviour (3 questions); how to form healthy habits (5 questions); how to break unhealthy habits (4 questions); and how to develop and evaluate habit-based behaviour change interventions (9 questions). CONCLUSIONS While our questions transcend research contexts, accumulating knowledge across studies of specific health behaviours, settings, and populations will build a broader understanding of habit change principles and how they may be embedded into interventions. We encourage researchers and practitioners to prioritise these questions, to further theory and evidence around how to create long-lasting health behaviour change.
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Affiliation(s)
- Benjamin Gardner
- Department of Psychology, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Madelynne A Arden
- Centre for Behavioural Science and Applied Psychology, Department of Psychology, Sociology & Politics, Sheffield Hallam University, Sheffield, UK
| | - Daniel Brown
- Department of Applied Psychology, Griffith University, Brisbane, Australia
| | - Frank F Eves
- School of Sport, Exercise and Rehabilitation Sciences, University of Birmingham, Birmingham, UK
| | - James Green
- School of Allied Health and Physical Activity for Health Research Cluster (Health Research Institute), University of Limerick, Limerick, Ireland
| | - Kyra Hamilton
- Griffith University and Menzies Health Institute Queensland, Mt Gravatt, Qld, Australia
| | - Nelli Hankonen
- Faculty of Social Sciences, University of Helsinki, Helsinki, Finland
| | - Jennifer Inauen
- Department of Health Psychology and Behavioral Medicine, Institute of Psychology, University of Bern, Bern, Switzerland
| | - Jan Keller
- Division Health Psychology, Department of Education and Psychology, Freie Universität Berlin, Berlin, Germany
| | - Dominika Kwasnicka
- Faculty of Psychology, SWPS University of Social Sciences and Humanities, Wrocław, Poland.,NHMRC CRE in Digital Technology to Transform Chronic Disease Outcomes, Melbourne School of Population and Global Health, University of Melbourne, Melbourne, Australia
| | - Sarah Labudek
- Network Aging Research (NAR), Heidelberg University, Heidelberg, Germany
| | - Hans Marien
- Department of Psychology, Utrecht University, Utrecht, The Netherlands
| | - Radomír Masaryk
- Institute of Applied Psychology, Faculty of Social and Economic Sciences, Comenius University Bratislava, Bratislava, Slovakia
| | - Nicola McCleary
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Canada.,School of Epidemiology and Public Health, Faculty of Medicine, University of Ottawa, Ottawa, Canada
| | - Barbara A Mullan
- Behavioural Science and Health Research Group, Curtin University, Perth, Australia
| | - Efrat Neter
- Department of Behavioral Sciences, Ruppin Academic Center, Emeq Hefer, Israel
| | - Sheina Orbell
- Department of Psychology, University of Essex, Essex, UK
| | - Sebastian Potthoff
- Department of Social Work, Education, and Community Wellbeing, Northumbria University, Newcastle upon Tyne, UK
| | - Phillippa Lally
- Research Department of Behavioural Science and Health, University College London, London, UK
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Dawson S, Girling CJ, Cowap L, Clark-Carter D. Psychological interventions for improving adherence to inhaled therapies in people with cystic fibrosis. Cochrane Database Syst Rev 2023; 3:CD013766. [PMID: 36989170 PMCID: PMC10054300 DOI: 10.1002/14651858.cd013766.pub2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/30/2023]
Abstract
BACKGROUND Adherence to treatment, including inhaled therapies, is low in people with cystic fibrosis (CF). Although psychological interventions for improving adherence to inhaled therapies in people with CF have been developed, no previous published systematic review has evaluated the evidence for efficacy of these interventions. OBJECTIVES The primary objective of the review was to assess the efficacy of psychological interventions for improving adherence to inhaled therapies in people with cystic fibrosis (CF). The secondary objective was to establish the most effective components, or behaviour change techniques (BCTs), used in these interventions. SEARCH METHODS We searched the Cochrane Cystic Fibrosis Trials Register, which is compiled from electronic database searches and handsearching of journals and conference abstract books. We also searched databases (PubMed; PsycINFO; EBSCO; Scopus; OpenGrey), trials registries (World Health Organization International Clinical Trials Registry Platform; US National Institutes of Health Ongoing Trials Register ClinicalTrials.gov), and the reference lists of relevant articles and reviews, with no restrictions on language, year or publication status. Date of search: 7 August 2022. SELECTION CRITERIA We included randomised controlled trials (RCTs) comparing different types of psychological interventions for improving adherence to inhaled therapies in people with CF of any age, or comparing psychological interventions with usual care. We included quasi-RCTs if we could reasonably assume that the baseline characteristics were similar in both groups. DATA COLLECTION AND ANALYSIS Two review authors independently assessed trial eligibility and completed data extraction, risk of bias assessments, and BCT coding (using the BCT Taxonomy v1) for all included trials. We resolved any discrepancies by discussion, or by consultation with a third review author as necessary. We assessed the certainty of the evidence using GRADE. MAIN RESULTS We included 10 trials (1642 participants) in the review (children and adolescents in four trials; adults in five trials; and children and adults in one trial). Nine trials compared a psychological intervention with usual care; we could combine data from some of these in a number of quantitative analyses. One trial compared a psychological intervention with an active comparator (education plus problem-solving (EPS)). We identified five ongoing trials. Psychological interventions were generally multi-component and complex, containing an average of 9.6 BCTs (range 1 to 28). The two most commonly used BCTs included 'problem-solving' and 'instruction on how to perform the behaviour'. Interventions varied in their type, content and mode of delivery. They included a problem-solving intervention; a paper-based self-management workbook; a telehealth intervention; a group training programme; a digital intervention comprising medication reminders and lung function self-monitoring; a life-coaching intervention; a motivational interviewing (MI) intervention; a brief MI intervention (behaviour change counselling); and a digital intervention combined with behaviour change sessions. Intervention duration ranged from 10 weeks to 12 months. Assessment time points ranged from six to eight weeks up to 23 months. Psychological interventions compared with usual care We report data here for the 'over six months and up to 12 months' time point. We found that psychological interventions probably improve adherence to inhaled therapies (primary outcome) in people with CF compared with usual care (mean difference (MD) 9.5, 95% confidence interval (CI) 8.60 to 10.40; 1 study, 588 participants; moderate-certainty evidence). There was no evidence of a difference between groups in our second primary outcome, treatment-related adverse events: anxiety (MD 0.30, 95% CI -0.40 to 1.00; 1 study, 535 participants), or depression (MD -0.10, 95% CI -0.80 to 0.60; 1 study, 534 participants), although this was low-certainty evidence. For our secondary outcomes, there was no evidence of a difference between groups in terms of lung function (forced expiratory volume in one second (FEV1) % predicted MD 1.40, 95% CI -0.20 to 3.00; 1 study, 556 participants; moderate-certainty evidence); number of pulmonary exacerbations (adjusted rate ratio 0.96, 95% CI 0.83 to 1.11; 1 study, 607 participants; moderate-certainty evidence); or respiratory symptoms (MD 0.70, 95% CI -2.40 to 3.80; 1 study, 534 participants; low-certainty evidence). However, psychological interventions may improve treatment burden (MD 3.90, 95% CI 1.20 to 6.60; 1 study, 539 participants; low-certainty evidence). The overall certainty of the evidence ranged from low to moderate across these outcomes. Reasons for downgrading included indirectness (current evidence included adults only whereas our review question was broader and focused on people of any age) and lack of blinding of outcome assessors. Psychological interventions compared with an active comparator For this comparison the overall certainty of evidence was very low, based on one trial (n = 128) comparing an MI intervention to EPS for 12 months. We are uncertain whether an MI intervention, compared with EPS, improves adherence to inhaled therapies, lung function, or quality of life in people with CF, or whether there is an effect on pulmonary exacerbations. The included trial for this comparison did not report on treatment-related adverse events (anxiety and depression). We downgraded all reported outcomes due to small participant numbers, indirectness (trials included only adults), and unclear risk of bias (e.g. selection and attrition bias). AUTHORS' CONCLUSIONS Due to the limited quantity of trials included in this review, as well as the clinical and methodological heterogeneity, it was not possible to identify an overall intervention effect using meta-analysis. Some moderate-certainty evidence suggests that psychological interventions (compared with usual care) probably improve adherence to inhaled therapies in people with CF, without increasing treatment-related adverse events, anxiety and depression (low-certainty evidence). In future review updates (with ongoing trial results included), we hope to be able to establish the most effective BCTs (or 'active ingredients') of interventions for improving adherence to inhaled therapies in people with CF. Wherever possible, investigators should make use of the most objective measures of adherence available (e.g. data-logging nebulisers) to accurately determine intervention effects. Outcome reporting needs to be improved to enable combining or separation of measures as appropriate. Likewise, trial reporting needs to include details of intervention content (e.g. BCTs used); duration; intensity; and fidelity. Large trials with a longer follow-up period (e.g. 12 months) are needed in children with CF. Additionally, more research is needed to determine how to support adherence in 'under-served' CF populations.
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Affiliation(s)
- Sophie Dawson
- Wolfson Cystic Fibrosis Centre, Nottingham University Hospitals NHS Trust, Nottingham, UK
- Staffordshire Centre for Psychological Research, School of Health, Science and Wellbeing, Staffordshire University, Stoke-on-Trent, UK
| | - Carla-Jane Girling
- Sheffield Clinical Trials Research Unit, ScHARR, University of Sheffield, Innovation Centre, Sheffield, UK
| | - Lisa Cowap
- Staffordshire Centre for Psychological Research, School of Health, Science and Wellbeing, Staffordshire University, Stoke-on-Trent, UK
| | - David Clark-Carter
- Staffordshire Centre for Psychological Research, School of Health, Science and Wellbeing, Staffordshire University, Stoke-on-Trent, UK
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Sandler RD, Wildman MJ. The CFHealthHub Learning Health System: Using Real-Time Adherence Data to Support a Community of Practice to Deliver Continuous Improvement in an Archetypal Long-Term Condition. Healthcare (Basel) 2022; 11:healthcare11010020. [PMID: 36611480 PMCID: PMC9818500 DOI: 10.3390/healthcare11010020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2022] [Revised: 12/15/2022] [Accepted: 12/16/2022] [Indexed: 12/24/2022] Open
Abstract
CFHealthHub is a learning health system active in over 50% of adult CF Centres in England, supporting people with CF to develop habits of self-care around adherence to preventative inhaled therapy. This is achieved through the delivery of a behaviour change intervention, alongside collection of objective adherence data. As is common to long-term conditions, adherence to prescribed therapy is low, despite clear evidence of beneficial long-term impact on outcomes. This article explains how CFHealthHub is underpinned by coherent conceptual frameworks. We discuss how application of implementation and quality improvement strategies has facilitated CFHealthHub's progression from a pilot study to a large, randomised control trial and now to a learning health system, becoming embedded within routine care. CFHealthHub is now able to support real-time health technology assessments, quality improvement and research trials and is in the process of being implemented in routine clinical care across participating centres.
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Affiliation(s)
- Robert D. Sandler
- Sheffield Adult Cystic Fibrosis Centre, Northern General Hospital, Sheffield S5 7AU, UK
- School of Health and Related Research (ScHARR), The University of Sheffield, Sheffield S1 4DA, UK
- Correspondence:
| | - Martin J. Wildman
- Sheffield Adult Cystic Fibrosis Centre, Northern General Hospital, Sheffield S5 7AU, UK
- School of Health and Related Research (ScHARR), The University of Sheffield, Sheffield S1 4DA, UK
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9
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Holland LR, Hilton J, Cookson K, Heinsch M, Gilligan C, Wark P. Understanding motivation for Australian adolescents and young adults with cystic fibrosis: Modifiable factors to support self-management. HEALTH & SOCIAL CARE IN THE COMMUNITY 2022; 30:e2712-e2723. [PMID: 34997788 DOI: 10.1111/hsc.13714] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/08/2020] [Revised: 11/07/2021] [Accepted: 12/23/2021] [Indexed: 06/14/2023]
Abstract
Cystic fibrosis (CF) is Australia's most common life limiting genetic condition, characterised by declining health and quality of life (QoL) over time. Despite improvements in treatment, there remains no cure. Adolescents and young adults (AYAs) with CF experience broad impacts to psychosocial functioning and QoL, as well as major transitions in care, all at a time of significant developmental change. The importance of developmentally tailored approaches to youth health care and self-management for young people with CF are well understood. However, to date, models of youth specific self-management have been lacking and motivation for young people with CF has not been well explored. This qualitative study, based on a social constructionist epistemological framework, addresses this gap. A total of 21 AYAs aged 15-30 years were recruited through one paediatric and one adult Australian CF centre. Demographic, clinical and distress data were captured to describe health complexity. Semi-structured interviews were audio-recorded, transcribed and analysed using thematic analysis. Participants were representative of Australian AYAs with CF by demography and clinical status. Alarmingly, over a third reported clinically significant distress. Two themes emerged. The first Identified impacts to motivation and self-management resulting from the challenges of managing CF, life and care. These included time and competing priorities, changing health statis, mental health, social factors, unmet needs and health system complexity. The second identified factors that support motivation including: achievement, meaning and purpose; consequence avoidance; and accountability. These results illustrate the importance of AYA specific, theoretically founded, holistic self-management models which extend beyond current theoretical approaches that aim to understand behaviour change or address barriers, in isolation from motivation. Improved approaches to care based on these findings are essential to foster positive behavioural change, support self-management and foster the best health outcomes for young people living with CF.
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Affiliation(s)
- Lucy Ruth Holland
- Faculty of Health and Medicine, The University of Newcastle, Newcastle, New South Wales, Australia
- School of Nursing, Queensland University of Technology, Brisbane, Queensland, Australia
| | - Jodi Hilton
- Department of Respiratory and Sleep Medicine, John Hunter Children's Hospital, Newcastle, New South Wales, Australia
| | - Kim Cookson
- Department of Respiratory and Sleep Medicine, John Hunter Hospital, Newcastle, New South Wales, Australia
| | - Milena Heinsch
- School of Medicine and Public Health & Behavioural Sciences, The University of Newcastle, Newcastle, New South Wales, Australia
| | - Conor Gilligan
- School of Medicine and Public Health & Behavioural Sciences, The University of Newcastle, Newcastle, New South Wales, Australia
| | - Peter Wark
- Centre for Healthy Lungs, Hunter Medical Research Institute, The University of Newcastle, Newcastle, New South Wales, Australia
- Department of Respiratory and Sleep Medicine, John Hunter Hospital, Newcastle, New South Wales, Australia
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10
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Volpi S, Carnovale V, Colombo C, Raia V, Blasi F, Pappagallo G. Use of mucoactive agents in cystic fibrosis: A consensus survey of Italian specialists. Health Sci Rep 2022; 5:e604. [PMID: 35677472 PMCID: PMC9169509 DOI: 10.1002/hsr2.604] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2021] [Revised: 01/27/2022] [Accepted: 02/06/2022] [Indexed: 11/12/2022] Open
Abstract
Background The goal of mucoactive therapies in cystic fibrosis (CF) is to enhance sputum clearance and to reduce a progressive decline in lung function over the patient's lifetime. We aimed to investigate the level of consensus among specialists from Italian CF Centers on appropriateness of therapeutic use of dornase alfa (rhDNase) for CF patients. Method A consensus on appropriate prescribing in CF mucoactive agents was appraised by an online Delphi method, based on a panel of 27 pulmonologists, coordinated by a Scientific Committee of six experts in medical care of patients with CF. Results Full or very high consensus was reached on several issues related to therapeutic use of dornase alfa for CF patients in clinical practice. Conclusions The consensus reached on a number of topics regarding use of mucoactive agents in patients with CF can help guide clinicians in daily practice based on expert experience and define the most appropriate therapeutic strategy for the individual patient.
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Affiliation(s)
- Sonia Volpi
- Cystic Fibrosis Center Azienda Ospedialiera Universitaria Integrata Verona Italy
| | - Vincenzo Carnovale
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico Cystic Fibrosis Center Milan Italy
| | - Carla Colombo
- Department of Translational Medical Science, Cystic Fibrosis Centre, Adult Unit University “Federico II” Naples Italy
| | - Valeria Raia
- Section of Pediatrics, Department of Translational Medical Sciences “University Federico II” Naples Italy
| | - Francesco Blasi
- Department of Internal Medicine Respiratory Unit and Adult Cystic Fibrosis Center Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico Milano Milan Italy
- Department of Pathophysiology and Transplantation Università degli Studi di Milano Milan Italy
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11
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Middour-Oxler B, Hirschmann K, Chace C, Collins L, Gordon C, Mann M, Swope C, George C. “Acquiring the Skills Needed to Communicate What Is in Our Teams’ Heart: Love, Compassion and Partnership”: Qualitative Analysis of Intact Multidisciplinary Teams’ Experience of Relationship-Centered Communication Training. J Patient Exp 2022; 9:23743735221103025. [PMID: 35677227 PMCID: PMC9168940 DOI: 10.1177/23743735221103025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
The Partnership Enhancement Program (PEP) is a 6-hour relationship-centered
communication training for intact cystic fibrosis (CF) teams. The aim of this
study was to analyze qualitative responses from survey participants regarding
their takeaways from the training. A total of 210 professionals participated in
20 pilot workshops at 19 care centers in the United States from November 2018 to
December 2019. After the workshop, qualitative feedback was captured by PEP
facilitators during a feedback gathering session or submitted immediately in
writing by participants. The manuscript team used grounded theory and
qualitative methods of coding to identify recurring themes across participant
responses. Thematic analysis revealed 5 primary themes and a web of
interconnected subthemes. Primary themes include the acquisition of skills to
improve communication, strengthened patient/provider connection, improved
quality of communication, improved team building, and the ability to change and
enhance practice. Participants who completed PEP training endorse acquiring
communication skills that increase coproduction of care with patients and
caregivers as well as improve relationships across the healthcare system.
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Affiliation(s)
- Brandi Middour-Oxler
- Children’s Healthcare of Atlanta + Emory University Cystic Fibrosis Care Center, Atlanta, GA, USA
| | | | - Carol Chace
- Children’s National Hospital, Washington, DC, USA
| | | | - Chandra Gordon
- University of Kansas Health System, Kansas City, KS, USA
| | - Michelle Mann
- Texas Children’s Hospital and Baylor College of Medicine, Houston, TX, USA
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12
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Lumley E, Drabble SJ, Scott A, Wildman MJ, O’Cathain A. Objective Nebuliser Adherence Data as "Proof" of Adherence in the Management of Cystic Fibrosis: A Qualitative Interview Study. Patient Prefer Adherence 2022; 16:771-780. [PMID: 35370406 PMCID: PMC8965329 DOI: 10.2147/ppa.s353434] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2022] [Accepted: 03/05/2022] [Indexed: 11/28/2022] Open
Abstract
PURPOSE Low adherence to medication via nebulisers is linked to poor clinical outcomes for people with Cystic Fibrosis (PWCF). Advances in technology allow electronic monitoring of nebuliser usage and feedback of objective adherence data to PWCF and clinical teams caring for them. CFHealthHub is a new intervention that collects and displays objective adherence data in easy-to-read formats with the aim of improving nebuliser adherence and health. There is little understanding of how objective adherence data is perceived by PWCF and healthcare professionals (HCPs). PATIENTS AND METHODS A qualitative study using semi-structured interviews with 22 PWCF and 31 HCPs who had used the CFHealthHub intervention. RESULTS Objective adherence data was welcomed by the majority of PWCF in the sample, and HCP delivering the intervention, because the data allowed PWCF to reflect on patterns of adherence or non-adherence. Ease of use and characteristics of data display were important, particularly the use of a "traffic light" system to allow PWCF to easily see if they were meeting their adherence targets. For PWCF objective adherence data was used as "proof to self", offering reassurance to high adherers, and a wake-up call to those with lower levels of adherence. It could also provide 'proof to others' where PWCF had higher levels of adherence than HCP or family members believed. The data could sometimes change HCP perceptions of PWCF's identities as poor adherers. Where adherence was not high, data was used to facilitate honest discussions between PWCF and HCPs about how to increase adherence. HCPs perceived that it was important to use the data positively to motivate, rather than criticise, PWCF. CONCLUSION Objective nebuliser adherence data in CFHealthHub can offer proof of adherence to PWCF and HCPs. It is important to use it constructively to facilitate discussions on how to improve adherence.
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Affiliation(s)
- Elizabeth Lumley
- Health and Care Research Unit, School of Health and Related Research, University of Sheffield, Sheffield, UK
- Correspondence: Elizabeth Lumley, Health and Care Research Unit, School of Health and Related Research, Regent Court, 30 Regent Street, Sheffield, S1 4DA, UK, Tel +44 114 2224294, Email
| | - Sarah J Drabble
- Health and Care Research Unit, School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Anne Scott
- Clinical Trials Research Unit, University of Sheffield, Sheffield, UK
| | - Martin J Wildman
- Adult Cystic Fibrosis Unit, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Alicia O’Cathain
- Health and Care Research Unit, School of Health and Related Research, University of Sheffield, Sheffield, UK
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13
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Wildman MJ, O’Cathain A, Hind D, Maguire C, Arden MA, Hutchings M, Bradley J, Walters SJ, Whelan P, Ainsworth J, Tappenden P, Buchan I, Elliott R, Nicholl J, Elborn S, Michie S, Mandefield L, Sutton L, Hoo ZH, Drabble SJ, Lumley E, Beever D, Navega Biz A, Scott A, Waterhouse S, Robinson L, Hernández Alava M, Sasso A. An intervention to support adherence to inhaled medication in adults with cystic fibrosis: the ACtiF research programme including RCT. PROGRAMME GRANTS FOR APPLIED RESEARCH 2021. [DOI: 10.3310/pgfar09110] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Background
People with cystic fibrosis frequently have low levels of adherence to inhaled medications.
Objectives
The objectives were to develop and evaluate an intervention for adults with cystic fibrosis to improve adherence to their inhaled medication.
Design
We used agile software methods to develop an online platform. We used mixed methods to develop a behaviour change intervention for delivery by an interventionist. These were integrated to become the CFHealthHub intervention. We undertook a feasibility study consisting of a pilot randomised controlled trial and process evaluation in two cystic fibrosis centres. We evaluated the intervention using an open-label, parallel-group randomised controlled trial with usual care as the control. Participants were randomised in a 1 : 1 ratio to intervention or usual care. Usual care consisted of clinic visits every 3 months. We undertook a process evaluation alongside the randomised controlled trial, including a fidelity study, a qualitative interview study and a mediation analysis. We undertook a health economic analysis using both a within-trial and model-based analysis.
Setting
The randomised controlled trial took place in 19 UK cystic fibrosis centres.
Participants
Participants were people aged ≥ 16 years with cystic fibrosis, on the cystic fibrosis registry, not post lung transplant or on the active transplant list, who were able to consent and not using dry-powder inhalers.
Intervention
People with cystic fibrosis used a nebuliser with electronic monitoring capabilities. This transferred data automatically to a digital platform. People with cystic fibrosis and clinicians could monitor adherence using these data, including through a mobile application (app). CFHealthHub displayed graphs of adherence data as well as educational and problem-solving information. A trained interventionist helped people with cystic fibrosis to address their adherence.
Main outcome measures
Randomised controlled trial – adjusted incidence rate ratio of pulmonary exacerbations meeting the modified Fuchs criteria over a 12-month follow-up period (primary outcome); change in percentage adherence; and per cent predicted forced expiratory volume in 1 second (key secondary outcomes). Process evaluation – percentage fidelity to intervention delivery, and participant and interventionist perceptions of the intervention. Economic modelling – incremental cost per quality-adjusted life-year gained.
Results
Randomised controlled trial – 608 participants were randomised to the intervention (n = 305) or usual care (n = 303). To our knowledge, this was the largest randomised controlled trial in cystic fibrosis undertaken in the UK. The adjusted rate of exacerbations per year (primary outcome) was 1.63 in the intervention and 1.77 in the usual-care arm (incidence rate ratio 0.96, 95% confidence interval 0.83 to 1.12; p = 0.638) after adjustment for covariates. The adjusted difference in mean weekly normative adherence was 9.5% (95% confidence interval 8.6% to 10.4%) across 1 year, favouring the intervention. Adjusted mean difference in forced expiratory volume in 1 second (per cent) predicted at 12 months was 1.4% (95% confidence interval –0.2% to 3.0%). No adverse events were related to the intervention. Process evaluation – fidelity of intervention delivery was high, the intervention was acceptable to people with cystic fibrosis, participants engaged with the intervention [287/305 (94%) attended the first intervention visit], expected mechanisms of action were identified and contextual factors varied between randomised controlled trial sites. Qualitative interviews with 22 people with cystic fibrosis and 26 interventionists identified that people with cystic fibrosis welcomed the objective adherence data as proof of actions to self and others, and valued the relationship that they built with the interventionists. Economic modelling – the within-trial analysis suggests that the intervention generated 0.01 additional quality-adjusted life-years at an additional cost of £865.91 per patient, leading to an incremental cost-effectiveness ratio of £71,136 per quality-adjusted life-year gained. This should be interpreted with caution owing to the short time horizon. The health economic model suggests that the intervention is expected to generate 0.17 additional quality-adjusted life-years and cost savings of £1790 over a lifetime (70-year) horizon; hence, the intervention is expected to dominate usual care. Assuming a willingness-to-pay threshold of £20,000 per quality-adjusted life-year gained, the probability that the intervention generates more net benefit than usual care is 0.89. The model results are dependent on assumptions regarding the duration over which costs and effects of the intervention apply, the impact of the intervention on forced expiratory volume in 1 second (per cent) predicted and the relationship between increased adherence and drug-prescribing levels.
Limitations
Number of exacerbations is a sensitive and valid measure of clinical change used in many trials. However, data collection of this outcome in this context was challenging and could have been subject to bias. It was not possible to measure baseline adherence accurately. It was not possible to quantify the impact of the intervention on the number of packs of medicines prescribed.
Conclusions
We developed a feasible and acceptable intervention that was delivered to fidelity in the randomised controlled trial. We observed no statistically significant difference in the primary outcome of exacerbation rates over 12 months. We observed an increase in normative adherence levels in a disease where adherence levels are low. The magnitude of the increase in adherence may not have been large enough to affect exacerbations.
Future work
Given the non-significant difference in the primary outcome, further research is required to explore why an increase in objective normative adherence did not reduce exacerbations and to develop interventions that reduce exacerbations.
Trial registration
Work package 3.1: Current Controlled Trials ISRCTN13076797. Work packages 3.2 and 3.3: Current Controlled Trials ISRCTN55504164.
Funding
This project was funded by the National Institute for Health Research (NIHR) Programme Grants for Applied Research programme and will be published in full in Programme Grants for Applied Research; Vol. 9, No. 11. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Martin J Wildman
- Sheffield Adult Cystic Fibrosis Centre, Northern General Hospital, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Alicia O’Cathain
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Daniel Hind
- Clinical Trials Research Unit, University of Sheffield, Sheffield, UK
| | - Chin Maguire
- Clinical Trials Research Unit, University of Sheffield, Sheffield, UK
| | - Madelynne A Arden
- Centre for Behavioural Science and Applied Psychology, Sheffield Hallam University, Sheffield, UK
| | - Marlene Hutchings
- Sheffield Adult Cystic Fibrosis Centre, Northern General Hospital, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Judy Bradley
- Wellcome-Wolfson Institute for Experimental Medicine, School of Medicine, Dentistry and Biomedical Sciences, Queen’s University Belfast, Belfast, UK
| | - Stephen J Walters
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Pauline Whelan
- Health eResearch Centre, Division of Imaging, Informatics and Data Sciences, School of Health Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester Academic Health Science Centre, Manchester, UK
| | - John Ainsworth
- Health eResearch Centre, Division of Imaging, Informatics and Data Sciences, School of Health Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester Academic Health Science Centre, Manchester, UK
| | - Paul Tappenden
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Iain Buchan
- Health eResearch Centre, Division of Imaging, Informatics and Data Sciences, School of Health Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester Academic Health Science Centre, Manchester, UK
- Department of Public Health and Policy, Institute of Population Health Sciences, University of Liverpool, Liverpool, UK
| | - Rachel Elliott
- Division of Population Health, Health Services Research and Primary Care, School of Health Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
| | - Jon Nicholl
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Stuart Elborn
- Wellcome-Wolfson Institute for Experimental Medicine, School of Medicine, Dentistry and Biomedical Sciences, Queen’s University Belfast, Belfast, UK
| | - Susan Michie
- Centre for Behaviour Change, University College London, London, UK
| | - Laura Mandefield
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Laura Sutton
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Zhe Hui Hoo
- Sheffield Adult Cystic Fibrosis Centre, Northern General Hospital, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Sarah J Drabble
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Elizabeth Lumley
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Daniel Beever
- Clinical Trials Research Unit, University of Sheffield, Sheffield, UK
| | - Aline Navega Biz
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Anne Scott
- Clinical Trials Research Unit, University of Sheffield, Sheffield, UK
| | - Simon Waterhouse
- Clinical Trials Research Unit, University of Sheffield, Sheffield, UK
| | - Louisa Robinson
- Clinical Trials Research Unit, University of Sheffield, Sheffield, UK
| | | | - Alessandro Sasso
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
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14
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Wildman MJ, O'Cathain A, Maguire C, Arden MA, Hutchings M, Bradley J, Walters SJ, Whelan P, Ainsworth J, Buchan I, Mandefield L, Sutton L, Tappenden P, Elliott RA, Hoo ZH, Drabble SJ, Beever D. Self-management intervention to reduce pulmonary exacerbations by supporting treatment adherence in adults with cystic fibrosis: a randomised controlled trial. Thorax 2021; 77:461-469. [PMID: 34556552 PMCID: PMC9016257 DOI: 10.1136/thoraxjnl-2021-217594] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2021] [Accepted: 08/15/2021] [Indexed: 12/02/2022]
Abstract
Introduction Recurrent pulmonary exacerbations lead to progressive lung damage in cystic fibrosis (CF). Inhaled medications (mucoactive agents and antibiotics) help prevent exacerbations, but objectively measured adherence is low. We investigated whether a multi-component (complex) self-management intervention to support adherence would reduce exacerbation rates over 12 months. Methods Between October 2017 and May 2018, adults with CF (aged ≥16 years; 19 UK centres) were randomised to the intervention (data-logging nebulisers, a digital platform and behavioural change sessions with trained clinical interventionists) or usual care (data-logging nebulisers). Outcomes included pulmonary exacerbations (primary outcome), objectively measured adherence, body mass index (BMI), lung function (FEV1) and Cystic Fibrosis Questionnaire-Revised (CFQ-R). Analyses were by intent to treat over 12 months. Results Among intervention (n=304) and usual care (n=303) participants (51% female, median age 31 years), 88% completed 12-month follow-up. Mean exacerbation rate was 1.63/year with intervention and 1.77/year with usual care (adjusted ratio 0.96; 95% CI 0.83 to 1.12; p=0.64). Adjusted mean differences (95% CI) were in favour of the intervention versus usual care for objectively measured adherence (9.5% (8.6% to 10.4%)) and BMI (0.3 (0.1 to 0.6) kg/m2), with no difference for %FEV1 (1.4 (−0.2 to 3.0)). Seven CFQ-R subscales showed no between-group difference, but treatment burden reduced for the intervention (3.9 (1.2 to 6.7) points). No intervention-related serious adverse events occurred. Conclusions While pulmonary exacerbations and FEV1 did not show statistically significant differences, the intervention achieved higher objectively measured adherence versus usual care. The adherence difference might be inadequate to influence exacerbations, though higher BMI and lower perceived CF treatment burden were observed.
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Affiliation(s)
- Martin J Wildman
- Sheffield Adult Cystic Fibrosis Centre, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK .,School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Alicia O'Cathain
- School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Chin Maguire
- Clinical Trials Research Unit, University of Sheffield, Sheffield, UK
| | - Madelynne A Arden
- Centre for Behavioural Science and Applied Psychology, Sheffield Hallam University, Sheffield, UK
| | - Marlene Hutchings
- Sheffield Adult Cystic Fibrosis Centre, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Judy Bradley
- Wellcome-Wolfson Institute for Experimental Medicine, School of Medicine Dentistry and Biomedical Sciences, Queen's University Belfast, Belfast, UK
| | - Stephen J Walters
- School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Pauline Whelan
- Health eResearch Centre - Division of Imaging, Informatics and Data Sciences, Faculty of Biology, Medicine and Health, The University of Manchester School of Health Sciences, Manchester, UK
| | - John Ainsworth
- Health eResearch Centre - Division of Imaging, Informatics and Data Sciences, Faculty of Biology, Medicine and Health, The University of Manchester School of Health Sciences, Manchester, UK
| | - Iain Buchan
- Health eResearch Centre - Division of Imaging, Informatics and Data Sciences, Faculty of Biology, Medicine and Health, The University of Manchester School of Health Sciences, Manchester, UK.,Department of Public Health and Policy, Institute of Population Health, University of Liverpool, Liverpool, UK
| | - Laura Mandefield
- School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Laura Sutton
- School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Paul Tappenden
- School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Rachel A Elliott
- Division of Population Health, Health Services Research and Primary Care, Faculty of Biology, Medicine and Health, The University of Manchester School of Health Sciences, Manchester, UK
| | - Zhe Hui Hoo
- Sheffield Adult Cystic Fibrosis Centre, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK.,School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Sarah J Drabble
- School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Daniel Beever
- Clinical Trials Research Unit, University of Sheffield, Sheffield, UK
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15
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Stuart G, D'Lima D. Perceived barriers and facilitators to attendance for cervical cancer screening in EU member states: a systematic review and synthesis using the Theoretical Domains Framework. Psychol Health 2021; 37:279-330. [PMID: 34121540 DOI: 10.1080/08870446.2021.1918690] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
AIMS To identify and synthesise peer-reviewed, published literature reporting perceived barriers and facilitators associated with cervical cancer screening attendance in EU member states with organised population-based screening programmes. METHODS Quantitative and qualitative studies reporting perceived barriers/facilitators to attendance for cervical cancer screening were searched for in databases Embase, HMIC, Medline and PsycInfo. Data were extracted and deductively coded to the Theoretical Domains Framework domains and inductive thematic analysis within domains was employed to identify specific barriers or facilitators to attendance for cervical cancer screening. RESULTS 38 studies were included for data extraction. Five theoretical domains ['Emotion' (89% of the included studies), 'Social influences' (79%), 'Knowledge' (76%), 'Environmental Context and Resources' (74%) and 'Beliefs about Consequences' (68%)] were identified as key domains influencing cervical cancer screening attendance. CONCLUSION Five theoretical domains were identified as prominent influences on cervical cancer screening attendance in EU member states with organised population-based screening programmes. Further research is needed to identify the relative importance of different influences for different sub-populations and to identify the influences that are most appropriate and feasible to address in future interventions.
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Affiliation(s)
- Gabriella Stuart
- Centre for Behaviour Change, Department of Clinical, Educational and Health Psychology, University College London, London, UK
| | - Danielle D'Lima
- Centre for Behaviour Change, Department of Clinical, Educational and Health Psychology, University College London, London, UK
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16
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Calthorpe RJ, Smith SJ, Rowbotham NJ, Leighton PA, Davies G, Daniels T, Gathercole K, Allen L, Elliott ZC, Smyth AR. What effective ways of motivation, support and technologies help people with cystic fibrosis improve and sustain adherence to treatment? BMJ Open Respir Res 2021; 7:7/1/e000601. [PMID: 32816834 PMCID: PMC7430440 DOI: 10.1136/bmjresp-2020-000601] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2020] [Revised: 05/07/2020] [Accepted: 05/29/2020] [Indexed: 12/18/2022] Open
Abstract
INTRODUCTION "What effective ways of motivation, support and technologies help people with cystic fibrosis improve and sustain adherence to treatment?" was identified as one of the James Lind Alliance Priority Setting Partnership's top 10 research questions in cystic fibrosis (CF). Using electronic questionnaires, we aimed to gain a deeper understanding of this research priority. METHOD The work was led by the steering group representative of the UK CF community consisting of patients, carers and healthcare professionals (HCPs). Electronic questionnaires were completed over a 4-week period and promoted via online forums such as Twitter, the UK CF Trust and US CF Foundation websites and via professional networks. Analysis of the closed questions was completed using Microsoft Excel, with keyword analysis and the final thematic analysis completed using NVivo software. RESULTS There were 313 respondents; 176/313 (56%) were from people with CF and their families. HCPs comprised of 10 professional groups accounting for 137/313 (44%) of respondents, with global involvement of participants with the majority from the UK. Common themes identified as impacting on adherence included: having no time, treatment burden, competing life demands, fatigue and the patient's general health. Having a routine was identified as the most frequently used motivational strategy, valued by both the patient and professional community. However, some strategies were valued more by HCPs than used in practice by patients; these included the use of short-term goal setting and technology use. CONCLUSION Adherence to treatment is crucial, however it is often suboptimal and strategies valued by HCPs to promote adherence are not always shared by patients. To promote adherence clinicians and researchers should be mindful that in a condition where treatment burden and time pressures are considerable, any interventions should focus on simplifying care and reducing treatment burden.
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Affiliation(s)
- Rebecca J Calthorpe
- University of Nottingham, Evidence Based Child Health Group, Division of Child Health, Obstetrics & Gynaecology, E Floor East Block, Queens Medical Centre, Nottingham, UK
| | - Sherie J Smith
- University of Nottingham, Evidence Based Child Health Group, Division of Child Health, Obstetrics & Gynaecology, E Floor East Block, Queens Medical Centre, Nottingham, UK
| | - Nicola J Rowbotham
- University of Nottingham, Evidence Based Child Health Group, Division of Child Health, Obstetrics & Gynaecology, E Floor East Block, Queens Medical Centre, Nottingham, UK
| | - Paul A Leighton
- Faculty of Medicine & Health Sciences, University of Nottingham, Nottingham, United Kingdom
| | - Gwyneth Davies
- UCL Great Ormond Street Institute of Child Health, London, UK
| | - Tracey Daniels
- Department of Physiotherapy, York Hull Adult Cystic Fibrosis Unit, York Teaching Hospital NHS Foundation Trust, York, North Yorkshire, UK
| | - Katie Gathercole
- University of Leeds, Leeds, West Yorkshire, UK.,Person with cystic fibrosis, Leeds, United Kingdom
| | - Lorna Allen
- Patient and Public Involvement Coordinator, Cystic Fibrosis Trust, London, UK
| | - Zoe C Elliott
- Parent of children with cystic fibrosis, Nottingham, Nottingham, UK
| | - Alan R Smyth
- University of Nottingham, Evidence Based Child Health Group, Division of Child Health, Obstetrics & Gynaecology, E Floor East Block, Queens Medical Centre, Nottingham, UK
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Keyworth C, Epton T, Goldthorpe J, Calam R, Armitage CJ. Patients' experiences of behaviour change interventions delivered by general practitioners during routine consultations: A nationally representative survey. Health Expect 2021; 24:819-832. [PMID: 33662180 PMCID: PMC8235898 DOI: 10.1111/hex.13221] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2020] [Revised: 01/29/2021] [Accepted: 02/05/2021] [Indexed: 12/14/2022] Open
Abstract
Background Consistent with the ‘Making Every Contact Count’ UK public health policy, general practitioners (GPs) are expected to provide patients with behaviour change interventions opportunistically. However, there is a belief widely held among GPs that patients neither want or need such interventions. We aimed to understand the following: (a) the characteristics of people attending GP appointments, (b) patients' needs for health behaviour change, (c) perceptions of appropriateness and helpfulness of interventions, and (d) factors associated with recall of receipt of interventions. Methods Cross‐sectional nationally representative online survey of UK adults who had attended GP clinics in the preceding four weeks (n = 3028). Data were analysed using descriptive statistics and binary logistic regression. Results 94.5% (n = 2862) of patients breached at least one health behaviour guideline, and 55.1% reported never having had a conversation with their GP about health behaviours. The majority of patients perceived intervention as appropriate (range 84.2%‐87.4% across behaviours) and helpful (range 82.8%‐85.9% across behaviours). Being male (OR = 1.412, 95% CI 1.217, 1.639), having a long‐term condition (OR = 1.514, 95% CI 1.287, 1.782) and a higher number of repeat GP visits (OR = 1.016, 95% CI 1.010, 1.023) were among factors associated with recall of receipt of interventions. Conclusions Patients perceived behaviour change intervention during routine GP consultations as appropriate and helpful, yet there are variations in the likelihood of receiving interventions according to sociodemographic factors. GPs could adopt a more proactive approach to behaviour change in patient consultations with the broad approval of patients. Patient or public contribution The questionnaire was piloted among a convenience sample prior to distribution.
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Affiliation(s)
- Chris Keyworth
- Manchester Centre for Health Psychology, Divisional of Psychology and Mental Health, School of Health Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, UK.,NIHR Greater Manchester Patient Safety Translational Research Centre, The University of Manchester, Manchester Academic Health Science Centre, Manchester, UK
| | - Tracy Epton
- Manchester Centre for Health Psychology, Divisional of Psychology and Mental Health, School of Health Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, UK
| | - Joanna Goldthorpe
- Manchester Centre for Health Psychology, Divisional of Psychology and Mental Health, School of Health Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, UK
| | - Rachel Calam
- Manchester Centre for Health Psychology, Divisional of Psychology and Mental Health, School of Health Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, UK
| | - Christopher J Armitage
- Manchester Centre for Health Psychology, Divisional of Psychology and Mental Health, School of Health Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, UK.,NIHR Greater Manchester Patient Safety Translational Research Centre, The University of Manchester, Manchester Academic Health Science Centre, Manchester, UK.,Manchester University NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
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18
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Exploring the Developmental Impact of Cystic Fibrosis on Lung Transplant Candidacy: Considerations for Adulthood. J Clin Psychol Med Settings 2021; 28:728-733. [PMID: 33515128 DOI: 10.1007/s10880-021-09761-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/04/2021] [Indexed: 10/22/2022]
Abstract
The average life expectancy for cystic fibrosis (CF) has increased over the past four decades resulting in a higher rate of adult CF patients. Adults seeking lung transplant to address CF-related advanced lung disease (ALD) represent a small, yet growing, subset of lung transplant recipients. Psychosocial factors such as adherence to medical recommendations, self-management of medical care, and caregiver support have been identified as positive prognostic factors in lung transplant outcomes. These factors are also implicated in the pediatric chronic illness literature and are crucial as patients begin to transition to a more autonomous and independent role in their own health management. Adults with CF facing ALD must navigate through another transitional phase as lung transplant requires additional supports and new expectations. A case series is used to highlight specific psychosocial considerations in this population and to explore the seemingly dichotomous relationship between independent self-management and caregiver support.
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Arden MA, Hutchings M, Whelan P, Drabble SJ, Beever D, Bradley JM, Hind D, Ainsworth J, Maguire C, Cantrill H, O'Cathain A, Wildman M. Development of an intervention to increase adherence to nebuliser treatment in adults with cystic fibrosis: CFHealthHub. Pilot Feasibility Stud 2021; 7:1. [PMID: 33390191 PMCID: PMC7780635 DOI: 10.1186/s40814-020-00739-2] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2020] [Accepted: 11/30/2020] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Cystic fibrosis (CF) is a life-limiting genetic condition in which daily therapies to maintain lung health are critical, yet treatment adherence is low. Previous interventions to increase adherence have been largely unsuccessful and this is likely due to a lack of focus on behavioural evidence and theory alongside input from people with CF. This intervention is based on a digital platform that collects and displays objective nebuliser adherence data. The purpose of this paper is to identify the specific components of an intervention to increase and maintain adherence to nebuliser treatments in adults with CF with a focus on reducing effort and treatment burden. METHODS Intervention development was informed by the Behaviour Change Wheel (BCW) and person-based approach (PBA). A multidisciplinary team conducted qualitative research to inform a needs analysis, selected, and refined intervention components and methods of delivery, mapped adherence-related barriers and facilitators, associated intervention functions and behaviour change techniques, and utilised iterative feedback to develop and refine content and processes. RESULTS Results indicated that people with CF need to understand their treatment, be able to monitor adherence, have treatment goals and feedback and confidence in their ability to adhere, have a treatment plan to develop habits for treatment, and be able to solve problems around treatment adherence. Behaviour change techniques were selected to address each of these needs and were incorporated into the digital intervention developed iteratively, alongside a manual and training for health professionals. Feedback from people with CF and clinicians helped to refine the intervention which could be tailored to individual patient needs. CONCLUSIONS The intervention development process is underpinned by a strong theoretical framework and evidence base and was developed by a multidisciplinary team with a range of skills and expertise integrated with substantial input from patients and clinicians. This multifaceted development strategy has ensured that the intervention is usable and acceptable to people with CF and clinicians, providing the best chance of success in supporting people with CF with different needs to increase and maintain their adherence. The intervention is being tested in a randomised controlled trial across 19 UK sites.
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Affiliation(s)
- M A Arden
- Centre for Behavioural Science and Applied Psychology, Sheffield Hallam University, 2.03a Heart of the Campus, Collegiate Crescent Campus, Sheffield, S10 2BQ, UK.
| | - M Hutchings
- Sheffield Adult Cystic Fibrosis Unit Sheffield Teaching Hospitals NHS Foundation Trust, Northern General Hospital, Herries Road, Sheffield, S5 7AU, UK
| | - P Whelan
- Health eResearch Centre-Farr Institute, Division of Imaging, Informatics and Data Sciences, School of Health Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester Academic Health Science Centre, Manchester, M13 9GB, UK
| | - S J Drabble
- School of Health and Related Research, University of Sheffield, Regent Court, 30 Regent Street, Sheffield, S1 4DA, UK
| | - D Beever
- Clinical Trials Research Unit, University of Sheffield, Regent Court, 30 Regent Street, Sheffield, S1 4DA, UK
| | - J M Bradley
- Centre for Experimental Medicine, School of Medicine, Dentistry and Biomedical Sciences, Queen's University, 97 Lisburn Road, Belfast, BT9 7BL, UK
| | - D Hind
- Clinical Trials Research Unit, University of Sheffield, Regent Court, 30 Regent Street, Sheffield, S1 4DA, UK
| | - J Ainsworth
- Health eResearch Centre-Farr Institute, Division of Imaging, Informatics and Data Sciences, School of Health Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester Academic Health Science Centre, Manchester, M13 9GB, UK
| | - C Maguire
- Clinical Trials Research Unit, University of Sheffield, Regent Court, 30 Regent Street, Sheffield, S1 4DA, UK
| | - H Cantrill
- Clinical Trials Research Unit, University of Sheffield, Regent Court, 30 Regent Street, Sheffield, S1 4DA, UK
| | - A O'Cathain
- School of Health and Related Research, University of Sheffield, Regent Court, 30 Regent Street, Sheffield, S1 4DA, UK
| | - M Wildman
- Sheffield Adult Cystic Fibrosis Unit Sheffield Teaching Hospitals NHS Foundation Trust, Northern General Hospital, Herries Road, Sheffield, S5 7AU, UK
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20
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Dawson S, Cowap L, Clark-Carter D, Girling CJ. Psychological interventions for improving adherence to inhaled therapies in people with cystic fibrosis. Hippokratia 2020. [DOI: 10.1002/14651858.cd013766] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Sophie Dawson
- Wolfson Cystic Fibrosis Centre; Nottingham University Hospitals NHS Trust; Nottingham UK
- Staffordshire Centre for Psychological Research, School of Life Sciences & Education; Staffordshire University; Stoke-on-Trent UK
| | - Lisa Cowap
- Staffordshire Centre for Psychological Research, School of Life Sciences & Education; Staffordshire University; Stoke-on-Trent UK
| | - David Clark-Carter
- Staffordshire Centre for Psychological Research, School of Life Sciences & Education; Staffordshire University; Stoke-on-Trent UK
| | - Carla-Jane Girling
- Sheffield Clinical Trials Research Unit, ScHARR; University of Sheffield, Innovation Centre; Sheffield UK
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21
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Hind D, Drabble SJ, Arden MA, Mandefield L, Waterhouse S, Maguire C, Cantrill H, Robinson L, Beever D, Scott A, Keating S, Hutchings M, Bradley J, Nightingale J, Allenby MI, Dewar J, Whelan P, Ainsworth J, Walters SJ, Wildman MJ, O'Cathain A. Feasibility study for supporting medication adherence for adults with cystic fibrosis: mixed-methods process evaluation. BMJ Open 2020; 10:e039089. [PMID: 33109661 PMCID: PMC7592300 DOI: 10.1136/bmjopen-2020-039089] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2020] [Revised: 07/27/2020] [Accepted: 09/29/2020] [Indexed: 12/30/2022] Open
Abstract
OBJECTIVES To undertake a process evaluation of an adherence support intervention for people with cystic fibrosis (PWCF), to assess its feasibility and acceptability. SETTING Two UK cystic fibrosis (CF) units. PARTICIPANTS Fourteen adult PWCF; three professionals delivering adherence support ('interventionists'); five multi-disciplinary CF team members. INTERVENTIONS Nebuliser with data recording and transfer capability, linked to a software platform, and strategies to support adherence to nebulised treatments facilitated by interventionists over 5 months (± 1 month). PRIMARY AND SECONDARY MEASURES Feasibility and acceptability of the intervention, assessed through semistructured interviews, questionnaires, fidelity assessments and click analytics. RESULTS Interventionists were complimentary about the intervention and training. Key barriers to intervention feasibility and acceptability were identified. Interventionists had difficulty finding clinic space and time in normal working hours to conduct review visits. As a result, fewer than expected intervention visits were conducted and interviews indicated this may explain low adherence in some intervention arm participants. Adherence levels appeared to be >100% for some patients, due to inaccurate prescription data, particularly in patients with complex treatment regimens. Flatlines in adherence data at the start of the study were linked to device connectivity problems. Content and delivery quality fidelity were 100% and 60%-92%, respectively, indicating that interventionists needed to focus more on intervention 'active ingredients' during sessions. CONCLUSIONS The process evaluation led to 14 key changes to intervention procedures to overcome barriers to intervention success. With the identified changes, it is feasible and acceptable to support medication adherence with this intervention. TRIAL REGISTRATION NUMBER ISRCTN13076797; Results.
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Affiliation(s)
- Daniel Hind
- Clincal Trials Research Unit, University of Sheffield, Sheffield, UK
| | - Sarah J Drabble
- School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Madelynne A Arden
- Centre for Behavioural Science and Applied Psychology, Sheffield Hallam University, Sheffield, UK
| | | | - Simon Waterhouse
- Clincal Trials Research Unit, University of Sheffield, Sheffield, UK
| | - Chin Maguire
- Clincal Trials Research Unit, University of Sheffield, Sheffield, UK
| | - Hannah Cantrill
- Clincal Trials Research Unit, University of Sheffield, Sheffield, UK
| | - Louisa Robinson
- Clincal Trials Research Unit, University of Sheffield, Sheffield, UK
| | - Daniel Beever
- Clincal Trials Research Unit, University of Sheffield, Sheffield, UK
| | - Alex Scott
- Clincal Trials Research Unit, University of Sheffield, Sheffield, UK
| | - Sam Keating
- Clincal Trials Research Unit, University of Sheffield, Sheffield, UK
| | - Marlene Hutchings
- Sheffield Adult Cystic Fibrosis Unit, Sheffield Teaching Hospitals NHS Foundation Trust, Northern General Hospital, Sheffield, Sheffield, UK
| | - Judy Bradley
- Wellcome-Wolfson Institute For Experimental Medicine, School of Medicine, Dentistry and Biomedical Sciences, Queen's University Belfast, Belfast, UK
| | - Julia Nightingale
- Wessex Adult Cystic Fibrosis Service, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Mark I Allenby
- Wessex Adult Cystic Fibrosis Service, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Jane Dewar
- Wolfson Cystic Fibrosis Centre, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Pauline Whelan
- Health eResearch Centre - Division of Imaging, Informatics and Data Sciences, School of Health Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester Academic Health Science Centre, Manchester, UK
| | - John Ainsworth
- Health eResearch Centre - Division of Imaging, Informatics and Data Sciences, School of Health Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester Academic Health Science Centre, Manchester, UK
| | - Stephen J Walters
- School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Martin J Wildman
- School of Health and Related Research, University of Sheffield, Sheffield, UK
- Sheffield Adult Cystic Fibrosis Unit, Sheffield Teaching Hospitals NHS Foundation Trust, Northern General Hospital, Sheffield, Sheffield, UK
| | - Alicia O'Cathain
- School of Health and Related Research, University of Sheffield, Sheffield, UK
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22
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Drabble SJ, O'Cathain A, Scott AJ, Arden MA, Keating S, Hutchings M, Maguire C, Wildman M. Mechanisms of Action of a Web-Based Intervention With Health Professional Support to Increase Adherence to Nebulizer Treatments in Adults With Cystic Fibrosis: Qualitative Interview Study. J Med Internet Res 2020; 22:e16782. [PMID: 32697197 PMCID: PMC7576463 DOI: 10.2196/16782] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2019] [Revised: 05/14/2020] [Accepted: 06/25/2020] [Indexed: 02/06/2023] Open
Abstract
Background Adherence to nebulizer treatments in adults with cystic fibrosis (CF) is often low. A new complex intervention to help adults with CF increase their adherence to nebulizer treatments was tested in a pilot randomized controlled trial (RCT) in 2 UK CF centers. Patients used a nebulizer with electronic monitoring capabilities that transferred data automatically to a digital platform (CFHealthHub) to monitor adherence over time and to a tailored website to display graphs of adherence data and educational and problem-solving information about adherence. A trained interventionist helped patients identify ways to increase their adherence. Objective This study aims to explore the mechanisms of action underpinning the intervention. Methods A qualitative interview study was conducted concurrently with a pilot RCT. In total, 25 semistructured interviews were conducted with 3 interventionists at 2 time points, 14 patients in the intervention arm of the trial, and 5 members of the multidisciplinary teams offering wider care to patients. A framework approach was used for the analysis. Results The intervention was informed by a theoretical framework of behavior change. There was evidence of the expected behavior change mechanisms of action. There was also evidence of additional mechanisms of action associated with effective telehealth interventions for self-management support: relationships, visibility, and fit. Patients described how building a relationship with the interventionist through face-to-face visits with someone who cared about them and their progress helped them to consider ways of increasing adherence to medication. Rather than seeing the visibility of adherence data to clinicians as problematic, patients found this motivating, particularly if they received praise about progress made. The intervention was tailored to individuals, but there were challenges in how the intervention fitted into some patients’ busy lives when delivered through a desktop computer. Conclusions The mechanisms of action associated with effective telehealth interventions for self-management operated within this new intervention. The intervention was modified to strengthen mechanisms of action based on these findings, for example, delivery through an app accessed via mobile phones and then tested in an RCT in 19 UK CF centers. Trial Registration International Standard Randomized Controlled Trial Number 13076797; http://www.isrctn.com/ISRCTN13076797
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Affiliation(s)
- Sarah J Drabble
- School of Health and Related Research, University of Sheffield, Sheffield, United Kingdom
| | - Alicia O'Cathain
- School of Health and Related Research, University of Sheffield, Sheffield, United Kingdom
| | - Alexander J Scott
- School of Health and Related Research, University of Sheffield, Sheffield, United Kingdom
| | - Madelynne A Arden
- Centre for Behavioural Science and Applied Psychology, Sheffield Hallam University, Sheffield, United Kingdom
| | - Samuel Keating
- School of Health and Related Research, University of Sheffield, Sheffield, United Kingdom
| | - Marlene Hutchings
- Sheffield Adult CF Centre, Sheffield Teaching Hospitals, Sheffield, United Kingdom
| | - Chin Maguire
- School of Health and Related Research, University of Sheffield, Sheffield, United Kingdom
| | - Martin Wildman
- Sheffield Adult CF Centre, Sheffield Teaching Hospitals, Sheffield, United Kingdom
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23
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Taj U, Schmidtke KA, Vlaev I, Read D. Choice of methods can determine which behavioral determinates are identified for targeting in future behavior change interventions: Increasing antibiotic adherence in Pakistan. J Health Psychol 2020; 27:1006-1013. [PMID: 33016143 PMCID: PMC8855384 DOI: 10.1177/1359105320962267] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
Abstract
When developing a behavioral intervention, formative research should be
conducted to determine which behavioral barriers and facilitators to
target. This is often done using qualitative interviews, but
quantitative surveys may also be used. The current study examines the
consequences of applying descriptive (rank order and
t-tests) versus predictive (regression)
quantitative analyses on intervention development, specifically for
increasing antibiotic course completion. For demonstrative purposes,
1892 adults in Pakistan completed a cross-sectional survey that
measures a comprehensive set of barriers/facilitators to their course
completion. The descriptive and predictive analyses disagreed
regarding which barriers/facilitators to prioritize. Reasons to prefer
predictive analyses are discussed.
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Affiliation(s)
- Umar Taj
- The Business School, University of Warwick, UK
| | | | - Ivo Vlaev
- The Business School, University of Warwick, UK
| | - Daniel Read
- The Business School, University of Warwick, UK
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24
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Eaton CK, Beachy S, McLean KA, Nicolais CJ, Bernstein R, Sáez-Clarke E, Quittner AL, Riekert KA. Misunderstandings, misperceptions, and missed opportunities: Perspectives on adherence barriers from people with CF, caregivers, and CF team members. PATIENT EDUCATION AND COUNSELING 2020; 103:1587-1594. [PMID: 32098744 DOI: 10.1016/j.pec.2020.02.025] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/23/2019] [Revised: 01/24/2020] [Accepted: 02/15/2020] [Indexed: 06/10/2023]
Abstract
OBJECTIVE To identify differences in perspectives of people with cystic fibrosis (PwCF) and caregivers versus healthcare providers on adherence barriers. Mismatched perspectives may lead to miscommunication and missed opportunities to reduce barriers and improve CF outcomes. METHODS PwCF, caregivers, and CF providers completed audio-taped, semi-structured interviews about adherence barriers. Interviews were transcribed and coded for themes. Themes were reviewed to identify when PwCF-caregiver perspectives differed from providers'. RESULTS Participants included 14 adolescents with CF (mean age = 15.89 years, 64 % female, 71 % Caucasian), 14 adults with CF (mean age = 30.03 years, 64 % female, 57 % Caucasian), 29 caregivers (76 % female; 72 % Caucasian), and 42 providers. Four barriers were identified that could generate miscommunication between PwCF-caregivers and providers: Tired = Fatigued/Sleepy versus Tired = Burnout, Vacation and Travel, Knowledge and Skills About CF Regimen, and Daily Habits or Routines. PwCF and caregivers used similar words as providers, but conceptualized barriers differently. PwCF and caregivers discussed barriers pragmatically, however, providers viewed certain barriers more abstractly or unidimensionally, or did not discuss them. CONCLUSIONS PwCF-caregivers and providers may not align in how they discuss barriers, which may contribute to miscommunication about adherence challenges. PRACTICE IMPLICATIONS Patient-centered communication strategies may enhance providers' understandings of PwCF-caregiver perspectives on barriers and facilitate adherence interventions.
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Affiliation(s)
- Cyd K Eaton
- The Johns Hopkins University School of Medicine, Department of Medicine, Baltimore, MD, USA.
| | - Sara Beachy
- The Johns Hopkins University School of Medicine, Department of Medicine, Baltimore, MD, USA
| | - Katherine A McLean
- Rush University Medical Center, Department of Pediatrics, Chicago, IL, USA
| | | | - Ruth Bernstein
- University of Miami, Department of Psychology, Coral Gables, FL, 33124, USA
| | | | | | - Kristin A Riekert
- The Johns Hopkins University School of Medicine, Department of Medicine, Baltimore, MD, USA
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25
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McGowan LJ, Powell R, French DP. How can use of the Theoretical Domains Framework be optimized in qualitative research? A rapid systematic review. Br J Health Psychol 2020; 25:677-694. [DOI: 10.1111/bjhp.12437] [Citation(s) in RCA: 50] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2020] [Revised: 05/09/2020] [Indexed: 11/27/2022]
Affiliation(s)
- Laura J. McGowan
- Manchester Centre for Health Psychology School of Health Sciences The University of Manchester UK
- Population Health Sciences Institute Newcastle University UK
| | - Rachael Powell
- Manchester Centre for Health Psychology School of Health Sciences The University of Manchester UK
| | - David P. French
- Manchester Centre for Health Psychology School of Health Sciences The University of Manchester UK
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26
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Martin R, Arden M, Porritt J, Wildman M, Naughton F. Investigating the Temporal Relationships between Symptoms and Nebuliser Adherence in People with Cystic Fibrosis: A Series of N-of-1 Observations. Healthcare (Basel) 2020; 8:healthcare8010022. [PMID: 31972991 PMCID: PMC7151352 DOI: 10.3390/healthcare8010022] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2019] [Revised: 01/08/2020] [Accepted: 01/13/2020] [Indexed: 12/12/2022] Open
Abstract
Treatment adherence in adults with cystic fibrosis (CF) is poor. One of the reasons identified for lack of adherence to nebulised treatments is that patients may not experience any immediate relief in their symptoms or notice changes as a result of taking their treatment, thus many report that they do not perceive there to be consequences of non adherence. The aim of the study was to investigate the temporal relationships between symptoms and adherence to nebulised treatments in adults with CF using an N-of-1 observational design. Six participants were recruited for a six-week period during which time they completed a daily online respiratory symptom questionnaire. Adherence to treatment was measured throughout the duration of the study using an eTrack® nebuliser that logged date and time of treatments taken. Data generated from each participant was analysed separately. There were significant relationships between pain and adherence for three participants, tiredness and adherence for one participant and cough and adherence for one participant. For all of these findings, the symptom and adherence were experienced on the same day. Extending the monitoring period beyond six weeks may provide increased insight into the complex relationship between symptoms and adherence in CF.
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Affiliation(s)
- Rosie Martin
- Centre for Behavioural Science and Applied Psychology, Sheffield Hallam University, Sheffield S10 2BQ, UK; (M.A.); (J.P.)
- Correspondence:
| | - Madelynne Arden
- Centre for Behavioural Science and Applied Psychology, Sheffield Hallam University, Sheffield S10 2BQ, UK; (M.A.); (J.P.)
| | - Jenny Porritt
- Centre for Behavioural Science and Applied Psychology, Sheffield Hallam University, Sheffield S10 2BQ, UK; (M.A.); (J.P.)
| | | | - Felix Naughton
- School of Health Sciences, University of East Anglia, Norwich NR4 7TJ, UK;
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27
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Muther EF, Butcher JL, Riekert KA. Understanding Treatment Adherence in Cystic Fibrosis: Challenges and Opportunities. Respir Med 2020. [DOI: 10.1007/978-3-030-42382-7_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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28
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Drabble SJ, O’Cathain A, Arden MA, Hutchings M, Beever D, Wildman M. When Is Forgetting Not Forgetting? A Discursive Analysis of Differences in Forgetting Talk Between Adults With Cystic Fibrosis With Different Levels of Adherence to Nebulizer Treatments. QUALITATIVE HEALTH RESEARCH 2019; 29:2119-2131. [PMID: 31303116 PMCID: PMC7322938 DOI: 10.1177/1049732319856580] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/09/2023]
Abstract
Forgetting is often cited as a reason why people struggle to adhere to treatments for chronic conditions. Interventions have tried to improve forgetting behavior using reminders. We used a discursive psychological approach to explore differences in how high and low adherers constructed forgetting their nebulizer treatments for cystic fibrosis. Interviews were conducted with 18 adults from a cystic fibrosis center in the United Kingdom. High adherers constructed forgetting treatments as occasional lapses in automaticity and temporary lapses in memory that they found easy to repair. Low adherers utilized forgetting to normalize more consistent nonadherence to treatments. However, it is important to contextualize forgetting as a discursive resource that helped these participants to negotiate moral discourses around adherence to treatment that reminder interventions cannot address; we therefore recommend a more behavioral, patient-focused, theory-driven approach to intervention development.
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Affiliation(s)
| | | | | | | | - Daniel Beever
- The University of Sheffield, Sheffield,
United Kingdom
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29
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Robinson L, Maguire C, Hoo ZH, Wildman MJ. Making the invisible visible: the availability and desirability of adherence data in routine CF care- findings from a national questionnaire survey. F1000Res 2019; 8:1904. [PMID: 32051757 PMCID: PMC6996524 DOI: 10.12688/f1000research.21033.2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/05/2019] [Indexed: 11/20/2022] Open
Abstract
Background: Inhaled medications for cystic fibrosis (CF) are effective but adherence is low. Clinicians find it difficult to estimate how much treatment people with CF (PWCF) take, whilst objective adherence measurement demonstrates that patients are poorly calibrated with a tendency to over-estimate actual adherence. The diagnostic approach to a PWCF with deteriorating clinical status and very low adherence is likely to be different to the approach to a deteriorating patient with optimal adherence. Access to objective adherence data in routine consultations could help to overcome diagnostic challenges for clinicians and people with CF. Attitudes of clinicians to the use and importance of routinely available adherence data is unknown. Methods: We conducted an online questionnaire survey with UK CF centres. We asked five questions relating to the current use and perception of objective measurements of adherence in routine care. Results: A total of eight CF centres completed the questionnaire. Few of the responding centres have adherence data readily available in routine clinics (13% of centres use medicines possession ratio; of centres with access to I-nebs® it was estimated that 17% of patients had I-neb data regularly available in clinics). All centres considered the availability of objectively measured adherence data to be important. Respondents identified that systems developed to provide adherence data in clinical practice must provide data to both clinicians and patients that is readily understood and easy to use. Conclusions: Centres perceived the availability of adherence data in routine care to be important but objective measures of adherence is rarely available at present.
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Affiliation(s)
- Louisa Robinson
- Clinical Trials Research Unit, University of Sheffield, Sheffield, South Yorkshire, S1 4DA, UK
| | - Chin Maguire
- Clinical Trials Research Unit, University of Sheffield, Sheffield, South Yorkshire, S1 4DA, UK
| | - Zhe Hui Hoo
- Sheffield Adult CF Centre, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, Yorkshire, S5 7AU, UK
- School of Health and Related Research, University of Sheffield, Sheffield, Yorkshire, S1 4DA, UK
| | - Martin J. Wildman
- Sheffield Adult CF Centre, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, Yorkshire, S5 7AU, UK
- School of Health and Related Research, University of Sheffield, Sheffield, Yorkshire, S1 4DA, UK
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